Sun21November1151AM 6

A 23-year-old female presents acutely unwell. She has a three month history of weight loss, tiredness and lethargy which has deteriorated over the last week. Six weeks previously she had been diagnosed with hypothyroidism by her general practitioner.

Investigations at that time showed:

Free T4 8.8 pmol/L (10-22)

Plasma TSH 5.5 mU/L (0.4-5)

She had started thyroxine 50 µg daily but had deteriorated over the last two weeks.

She is a non-smoker, drinks no alcohol and takes the oral contraceptive pill. Her mother and maternal grandmother have both been diagnosed with hypothyroidism and take thyroxine.

On examination she appears unwell and mildly dehydrated. She has a temperature of 37.5°C and has a BMI of 21.3 kg/m2. Her blood pressure is 72/44 mmHg, with a pulse of 100 beats per minute. Examination of the cardiovascular system is otherwise normal. No abnormalities are encountered on respiratory or abdominal examination. Brief neurological examination is normal and both plantars are flexor.

As yet, the investigations requested by the house officer are unavailable.

In the meantime what is the most appropriate immediate management of this patient?

(Please select 1 option)

Intravenous cefotaxime

Intravenous fluids and hydrocortisone Correct

Intravenous thyroxine (T4)

Intravenous thyronine (T3)

Intravenous glucose

Explanation

The patient has had a long history of weight loss and fatigue and was diagnosed with hypothyroidism based upon a slightly low T4 and slightly high TSH. Thyroxine was prescribed but this has precipitated a deterioration of the underlying condition such that the patient presents with features suggesting an addisonian crisis.

Thus is a medical emergency and should be treated with intravenous fluids and hydrocortisone. An appropriate test would be a short Synacthen test which could be completed in 30 minutes. Adrenal autoantibodies are likely to be positive in over 80% of cases.

Sick euthyroidism is a recognised feature of Addison's disease and treatment with thyroxine may exacerbate the condition and precipitate acute hypoadrenalism.

Answer Statistics

1

2%

2

91%

3

3%

4

6%

Times answered: 316